BMJ Press Releases, Saturday 28 September 1996
Volume 313 No 7060

EMBARGOED 00.01 HRS 27 SEPTEMBER 1996

CHILD INJURY DEATHS - A CLASS DIVIDE

[Does the decline in child injury mortality vary by social class? A comparison of class specific mortality in 1981 and 1991]

Children in the poorest social class are five times more likely to die from accidental injury than children in the highest social class. Although accidental death rates have fallen for all children, evidence published in this week's BMJ shows the gap between rich and poor is widening.

Dr Ian Roberts, Director of the Child Health Monitoring Unit at the institute of Child Health, London, has examined injury death rates for children up to 15 years old. In the early 1980s the injury death rate for children in social class V was 3.5 times that of children in social class 1. For the four years 1989-1992 the child injury death rate in social class V was 5 .0 times that of social class 1. If the trend continues, Dr Roberts warns that the Government's Health of the Nation target to reduce child injury mortality as a priority will be met for the non manual classes but not for those in the manual classes.

Pedestrian accidents and fire were the leading specific causes of child injury death in 1991, Motor vehicle accidents in general accounted for 44 per cent of child injury deaths in the early 1990s compared with 51 per cent in the early 1980s - but the downward trend was much steeper for children from richer homes.

Fire deaths among children in social classes IV and V increased by 18 per cent and 39 per cent respectively between 1981 and 1991 but decreased for children in social classes I and II. "Fire risk is greatest for those living in the poorest council housing and in temporary accommodation" writes Dr Roberts. In the BMJ letters section he point out that about 70 children a year die as a result of fires in the home in England and Wales. Evidence shows that in Oklahoma City, USA, a free distribution of smoke alarms prevented an estimated 39 deaths or serious injury. Yet in Britain, families most likely to benefit from smoke alarms are least likely to be able to afford them" A free distribution of smoke alarms by health visitors and community care organisations would be worthy of consideration, says Dr Roberts.

Contact: Dr Ian Roberts
Director

Child Health Monitoring Unit
Institute of Child Health
London WC1N 1EH

Tel: 0171 242 9789
Fax: 0171 813 8233
E-mail: Ian.Roberts@ICH.UCL.AC.UK

AN APPLE A DAY....A STUDY OF EATING HABITS AND MORTALITY

[Dietary habits and mortality in 11,000 vegetarians and health conscious people: results of a 17 year follow up]

Eating fresh fruit every day is good for you, says a report in this week's BMJ.

Dr Timothy Key of the Imperial Cancer Research Fund, and colleagues, report on a study of 10,771 health conscious men and women (43 per cent of them vegetarians) over an average period of 17 years. "Overall the cohort had a mortality about half that of the general population" says the paper. The 4,336 men and 6435 women in the study were recruited in the 1970s and followed up until March 1995. After smoking habits had been adjusted for, daily consumption of fresh fruit was found to be associated with a 24 per cent reduction in deaths from ischaemic heart disease, a 32 per cent reduction in deaths from cerebrovascular disease ( strokes), and a 21 per cent reduction in deaths from all causes compared with people who ate fresh fruit less frequently.

Contact: Dr Timothy Key

Imperial Cancer Research Fund
Cancer Epidemiology Unit
Radcliffe Infirmary
Oxford OX2 6HE

Tel: 01865 311933
Fax: 01865 310545
E-mail: key@ICRF.ICNET.UK

[Prevalence of obesity is low in people who do not eat meat]

If you don't eat meat, you are less likely to be fat. This is the message of a letter from Dr Tim Key in the same issue of the BMJ. A study based on 21,000 health conscious people showed that meat eaters were more likely to be clinically obese than fish eaters, vegans or vegetarians. Dr Key reports that among the meat eaters, 9.2 per cent of the women and 6.4 per cent of the men were clinically obese. These figures fail to reach the government's Health of the Nation targets for reducing obesity.

Contact: Dr Timothy Key

as above

CAN A FETUS FEEL PAIN?

[Infant and neonatal pain: anaesthetists' perceptions and prescribing patterns]

[Can a fetus feel pain? "Fetal Pain" is a misnomer]

[Can a fetus feel pain? Probably no pain in the absence of "self"]

[Can a fetus feel pain? Reflex responses do not necessarily signify pain]

[Can a fetus feel pain? We don't know; better to err on the safe side from mid-gestation]

Medical debate over whether a fetus can feel pain, and if so at what stage of development, continues in a cluster of papers published in this week's BMJ.

Issues are clearer after the birth. Until 10 years ago new born babies and infants were assumed to be incapable of perceiving pain but new research, also in this week's BMJ shows all babies now receive pain killers during surgery. A survey by Jonathan de Lima, of Great Ormond Street Hospital, and colleagues, showed almost universal agreement among paediatric anaesthetists that after birth all age groups of babies perceived pain and were treated accordingly.

The issue of consciousness is central to expert debate about pain in the developing fetus. Dr Stuart Derbyshire argues that whether a fetus feels pain hinges not on its biological development but on its conscious development. Previous research has highlighted 26 weeks as the development point at which the possibility of a fetus experiencing pain arises. A fetus has yet to experience the developmental process which leads to a conscious appreciation of pain as distinct from reflex response. "Fetal pain is therefore a misnomer at any stage of fetal development" says Dr Derbyshire.

He states :"We suggest that fetal response to invasive procedures do not indicate a conscious appreciation of pain. Scientific evidence suggests that women considering abortion can be assured that fetuses do not experience pain in the way that those who oppose abortion claim. Parliamentary claims that a fetus may feel pain should be viewed as a tactic in the effort to undermine public confidence in the current abortion legislation."

Zbigniew Szawarski in the BMJ argues that a fetus probably feels no pain in the absence of a sense of self. Using current definitions of feeling and pain, the answer to "Can a fetus feel pain?" must be "no", writes Adrian Lloyd Thomas , Consultant in paediatric anaesthesia and pain management at Great Ormond Street Hospital. However, the nervous system in the unborn baby mounts protective responses to tissue injury starting just before the last trimester. Evidence is growing that noxious stimuli may effect normal neural development. More research is urgently needed, writes the author in the BMJ and "it may now be pertinent to consider pain control in medical procedures for fetuses in the last trimester."

Vivette Glover in the BMJ argues that it seems likely a fetus can feel pain when certain neural connections become established. Though we cannot measure pain, we can measure fetal hormonal stress responses. "The fetus may be subjected to different kinds of stress or pain during invasive procedures, termination, and even birth". While terminations are usually carried out before 20 weeks of pregnancy "when it is particularly uncertain if the fetus feels anything at all" Vivette Glover suggests that until there is evidence to the contrary, "those conducting later terminations should try to use methods that are likely to cause as little suffering as possible." This must be balanced against distress to the mother caused by the method used.

Contact: Dr Adrian Lloyd-Thomas
Consultant in paediatric anaesthesia and acute pain management

Dept of Anaesthesia
Great Ormond Street Hospital for Children
London WC1N 3JH

Tel:0171 829 8865
Fax: 0171 829 8866

Contact: Dr S.W.G Derbyshire

Dept Radiology
University of Pittsburgh Medical Centre
200 Lothrop Street
Pittsburgh
PA 15213 2582
USA

Tel: 001 412 647 0736
Fax: 001 412 647 0700

or co-author Ann Ferudi

Tel 0171 580 9360

Contact: Zbigniew Szawarski

Centre for Philosophy and Health Care
University of Wales Swansea
SA2 8PP

Tel: 01792 295611
Fax: 01792 295769
Email: Z.Szawarski@Swansea.ac.uk

Contact: Dr Adrian Lloyd Thomas

see above

Contact: Dr Vivette Glover
Clinical Scientist

Dept of Paediatrics
Royal Postgraduate Medical School
Institute of Obstetrics and Gynaecology
Queen Charlotte's and Chelsea Hospital
London W6 0XG

Tel:0181 740 3524
Fax: 0181 741 1948

THE LANGUAGE OF RISK

[Cancer:science and society and the communication of risk]

A classification scheme to explain the nature of risk is suggested by the Government's Chief Medical Officer, Sir Kenneth Calman in this week's BMJ. In an attempt to answer the public's questions on what is meant by "safe", the scheme would spell out the degree of risk in categories ranging from "negligible" to "high".

Sir Kenneth, whose annual report came out this week, writes :"Risks are described in a variety of ways such as negligible, minimal, remote, very small, small etc. The public and professionals are rightly confused by such a range of words." As well as indicating the size of the risk, the classification scheme would need to cover concepts such as avoidability, justifiability and seriousness. Public perception was also very important.

If Sir Kenneth's scheme was adopted, risks would be classified as either negligible (an adverse event in less than one per million eg being struck by lightning), minimal (a risk in the order of between 1 in a million and 1 in 100,000 eg a railway accident), very low (between 1 in 100,000 and 1 in 10,000 eg getting leukaemia) low (between 1 in 10,000 and 1 in 1,000 eg getting influenza) moderate (1 in 1000 to 1 in 100 eg adverse events from smoking 10 cigarettes a day) and high (a risk greater than 1 in 100 eg transmission of HIV from mother to child). An unknown risk would be when the risk was unquantifiable eg at the beginning of the HIV epidemic.

Contact: Sir Kenneth Calman
Chief Medical Officer

Department of Health

Tel: 0171 210 5233
Fax: 0171 210 5434

WELCOME BREAK

[Doctors' retainer scheme in Scotland: time for change?]

The doctors' retainer scheme in Scotland - designed to provide a career break for such things as child care - is flawed but welcome, reports a paper in this week's BMJ. The scheme encourages doctors temporarily unable to practise because of domestic commitments to stay in touch with work and training in order to eventually return to work. A survey by Dr Alison Douglas and Ian McCann showed that over 46 per cent of scheme members would have left medicine if the scheme had not existed. Doctors in the scheme would like to be able to work more sessions per week. At present there are no national guidelines on pay and conditions and 53 per cent of scheme members do not receive BMA rates. Many doctors feel the scheme needs modernising.

Contact: Dr Alison Douglas

Postgraduate Medical Department
Aberdeen Postgraduate Centre
Aberdeen Medical School
AB25 2ZD

Tel: 01224 492828
Fax: 01224 276173

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EMBARGO: 00.01 HRS FRIDAY 27 SEPTEMBER 1996

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